Persistence With Oral Anticoagulants in Nonvalvular AF

Nov 01, 2021
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Authors:
Toorop MM, Chen Q, Tichelaar VY, Cannegieter SC, Lijfering WM.
Citation:
Predictors, Time Course, and Outcomes of Persistence Patterns in Oral Anticoagulation for Non-Valvular Atrial Fibrillation: A Dutch Nationwide Cohort Study. Eur Heart J 2021;42:4126-4137.
Summary By:
Geoffrey D. Barnes, MD, MSc, FACC

Quick Takes

  • More than one-quarter of patients with nonvalvular atrial fibrillation (NVAF) were nonpersistent on direct oral anticoagulant (DOAC) therapy by 4 years in a Dutch national registry.
  • Nonpersistence with DOAC therapy for patients with NVAF is associated with increased risk of ischemic stroke or stroke-related mortality.
  • Select patient characteristics (age, sex, prior stroke, and stroke risk) are associated with increased persistence of DOAC therapy.

Study Questions:

What is the persistence with direct oral anticoagulants (DOACs) and its association with prognosis among a nationwide cohort of patients with nonvalvular atrial fibrillation (NVAF)?

Methods:

Patients who were naïve to DOAC therapy who started to use DOACs for stroke prevention in NVAF between 2013 and 2018 were included from a Dutch national registry. Persistence was defined as continual use of DOAC therapy, meaning no gap of ≥100 days. Predictors of persistence and association of persistence with ischemic stroke outcomes were assessed using multivariable Cox regression.

Results:

Among 93,048 patients, 75.7% had a baseline CHA2DS2-VASc score ≥2. The cumulative incidence of DOAC persistence was 88.1% (95% confidence interval [CI], 87.9-88.3%) at 1 year, 82.6% (82.3-82.9%) at 2 years, 77.7% (77.3-78.1%) at 3 years, and 72.0% (71.5-72.5%) at 4 years after starting therapy. Baseline characteristics associated with better persistence include female sex, age range 65-74 (vs. both older and younger), permanent NVAF, prior use of vitamin K antagonists, prior stroke or transient ischemic attack, and a CHA2DS2-VASc score ≥2. Nonpersistence with DOAC therapy was associated with an increased risk of the composite outcome of ischemic stroke ± death (adjusted hazard ratio [aHR], 1.79; 95% CI, 1.49-2.15) and ischemic stroke alone (aHR, 1.58; 95% CI, 1.29-1.93) compared to patients who persisted on DOAC therapy.

Conclusions:

The authors concluded that at least one-quarter of patients with NVAF were nonpersistent with DOAC therapy within 4 years.

Perspective:

DOAC therapy is currently first-line therapy for patients with NVAF to reduce the risk of ischemic stroke. However, the benefit of DOAC therapy is only realized by patients when they are taking their medication. Many patients discontinue therapy for a wide variety of reasons, including side effects (e.g., bleeding) and cost. This study from the Netherlands reports on the 4-year persistence of DOAC therapy. While the authors note that more than one-quarter were nonpersistent at 4 years, these rates are much higher than other studies, including those conducted in the United States. Medication-related cost issues may be more prevalent in some countries that others. Nonetheless, this study confirms that persistence with DOAC therapy is associated with lower risk of ischemic stroke and stroke-related death.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Brain Ischemia, Hemorrhage, Ischemic Attack, Transient, Ischemic Stroke, Secondary Prevention, Stroke, Vascular Diseases, Vitamin K


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